ADHD. Information for parents

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1 ADHD Information for parents

2 Disclosure I am a general pediatrician with no special training in the diagnosis or treatment of ADHD or coexisting mental health issues. My goal is to provide general information about the diagnosis and management of ADHD as a general pediatrician Most of the information in this talk is from the AAP Practice Guidelines for the diagnosis and management of ADHD, the National Initiative for Children s Healthcare Quality Initiative, and Up to Date (a peer-reviewed, evidence based website for physicians)

3 Definition 1. ADHD is a disorder that manifests in early childhood with symptoms of hyperactivity, impulsivity, and/or inattention. The symptoms affect cognitive, academic, behavioral, emotional and social functioning. 2. Prevalence in school age children is estimated to be between 8-10 % 3. More males are affected than females

4 What causes ADHD? The exact cause of ADHD is unknown. There is a suspected genetic abnormality which causes an imbalance of neurotransmitters in the brain In some studies, identical twins have a 92% concordance rate Prenatal tobacco exposure has been shown to increase the risk of ADHD Dietary influences have not been shown to impact the behaviors associated with ADHD

5 What are the symptoms of ADHD? Hyperactivity and Impulsivity Components: Excessive fidgeting Difficulty staying in seat Inappropriate running around Difficulty playing quietly Always on-the-go Excessive talking Difficulty waiting his/her turn Frequent interruptions or intrusive behavior

6 What are the symptoms of ADHD? Inattentive Components: Careless mistakes Difficulty maintaining focus Seems to not listen Fails to follow through on tasks Poor organizational skills Loses items (books, school work, etc.) Easily distracted Forgetful

7 What distinguishes normal behavior and ADHD? Symptoms must be present in more than one setting (i.e. School and home) Symptoms must be present for longer than 6 months Symptoms must be present since early childhood (usually before age 7 year) Symptoms impair social and academic activities Symptoms are excessive for the developmental age of the child Symptoms are not causes by a medical or mental disorder

8 Are there other conditions frequently associated with ADHD? Coexisting conditions are common in children with ADHD Oppositional defiant disorder Conduct disorder (found in up to 30%) Anxiety disorder (20-30%) Depression (30%) Learning disability (20-60%) In one study, as many as 40% of children with ADHD had a coexisting reading or language disability

9 How is ADHD diagnosed? There is no single test that can diagnosis ADHD A diagnosis of ADHD is made based on specific criteria that have been established Your pediatrician, or diagnosing physician, will likely take a thorough developmental, school, and medical history. If suspicious for ADHD, he/she will likely have the parents and teachers fill out behavioral questionnaires. If the criteria are met and no other diagnosis can be made to explain the symptoms, a presumptive diagnosis of ADHD is made and treatment is initiated. Frequent re-evaluations are required. IF there is no response to treatment, other etiologies need to be re-considered

10 How is ADHD treated? ADHD is a chronic medical condition and should be managed as such with regular monitoring of treatment outcomes Goals of the treatment should be clearly defined and REALISTIC Improved relationships with family/teachers/friends Improved academic performance (completing assignments, turning in work) Most pediatric ADHD can be managed by your primary care physician, but if coexisting conditions exist, your child may need referral to a psychiatrist or developmental specialist for management

11 How is ADHD treated in preschool children (age 4y-5y)? Initial treatment recommendation for the preschool age child is BEHAVIOR THERAPY This is done with specific behavior modifications by the parents and teachers There are websites and books that describe different techniques but referral to a behavior therapist may be helpful for the parents. Some interventions include but are not limited to: Maintain a routine daily schedule Keep distractions low Use a token economy which reward positive behaviors Use charts and checklists as reminders Limit choices Remain calm when your child s behavior escalates

12 How is ADHD treated in elementary school and high school (6y and older)? A combination of behavioral modifications and pharmacotherapy In younger children and when parents do not want to begin a trial of medications, behavior modifications are the first line treatments Medications are started if criteria for ADHD are met, there are no contraindications to the medications, and there is no substance abuse Goal of treatment is to improve the core symptoms and targeted goals Rating scales and input from teachers and parents are needed at follow-up appoints to assess response to therapy Daily home/school report cards can help teachers and parents track the response

13 What medications are used to treat ADHD? Stimulants Stimulants are the first line treatment in most cases They have a long record of use with good response and known side effects They have a rapid onset of action which allows benefits to be seen quickly There are two main categories of stimulant medications Methylphenidates (Concerta, Ritalin, Focalin, Metadate, Quillivant, Daytrana) Amphetamine derivatives (Adderall, Dexedrine, Vyvanse) Stimulant medications are started at a specified starting dose and increased at weekly intervals until goals are achieved with minimum side effects.

14 What are the side effects of the stimulant medications? Common side effects: Decreased appetite, sleep problems, behavioral rebound More transient side effects include headache and stomachache Infrequent side effects: Weight loss, growth suppression Increased heart rate or blood pressure; dizziness Hallucinations, mania Exacerbation of tics/ Tourette s syndrome

15 What can I do about the side effects? If the side effects are severe, the medication may need to be changed to a different stimulant. There are many strategies to deal with the side effects that can be discussed with your pediatrician Decreased appetite: Take dose after a meal, offer frequent snacks, drug holidays Sleep problems: move the dose to an earlier time, bedtime routine

16 What other medications are available? Atomoxetine (Straterra) Titrated to usual effective dose which is based on weight Takes several weeks to see full response to therapy Side effects: stomachache, headache, decreased appetite, mood swings, fatigue SERIOUS side effect: may increase risk of suicidal thoughts and actions Alpha-adrenergic blockers (Kapvay, Intuniv) Used if poor response or excessive side effects with stimulants or atomoxetine Side effects: low blood pressure, fatigue/sleepiness CAN NOT be stopped suddenly, need to wean the dose if taking higher than the starting dose

17 So many medicines, how do you know which is best? Unfortunately, pharmacologic treatment of ADHD may be a bit of trial and error to find the best medication and dose for a child. Stimulants are the recommended first line treatment. Which stimulant? Long-acting (10-12 hr.) vs. short-acting (4-8 hr.) Can the child swallow a pill Cost; is a generic available Non-stimulants may be the initial treatment if contraindications exist to stimulants and are used when the side effects of stimulants outweigh their benefit or are not effective

18 Will my child be on medication forever? The goal of medical and behavioral interventions is to optimize your child s behavior, academic performance, and social interactions. In general, the hyperactive and impulsive behaviors diminish over time more so than the inattentive behaviors. It is not unreasonable to have a planned trial period off medication once your child has been stable for a few years. This should be done in conjunction with your pediatrician with frequent scheduled follow-up.

19 Thank you.

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